Nerve Capping Techniques for Neuroma Management: A Comprehensive Literature Review.

BACKGROUND/AIM OF THE STUDY: Nerve capping is a method of neuroma treatment or prevention that consists of the transplantation of a proximal nerve stump into an autograft or other material cap, after surgical removal of the neuroma or transection of the nerve. The aim was to reduce neuroma formation and symptoms by preventing neuronal adhesions and scar tissue. In this narrative literature review, we summarize the studies that have investigated the effectiveness of nerve capping for neuroma management to provide clarity and update the clinician's knowledge on the topic. METHODS: A systematic electronic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was performed in the PubMed database combining "neuroma," "nerve," "capping," "conduit," "treatment," "management," "wrap," "tube," and "surgery" as search terms. English-language clinical studies on humans and animals that described nerve capping as a treatment/prevention technique for neuromas were then selected based on a full-text article review. The data from the included studies were compiled based on the technique and material used for nerve capping, and technique and outcomes were reviewed. RESULTS: We found 10 applicable human studies from our literature search. Several capping materials were described: epineurium, nerve, muscle, collagen nerve conduit, Neurocap (synthetic copolymer of lactide and caprolactone, which is biocompatible and resorbable), silicone rubber, and collagen. Overall, 146 patients were treated in the clinical studies. After surgery, many patients were completely pain-free or had considerable improvement in pain scores, whereas some patients did not have improvement or were not satisfied after the procedure. Nerve capping was used in 18 preclinical animal studies, using a variety of capping materials including autologous tissues, silicone, and synthetic nanofibers. Preclinical studies demonstrated successful reduction in rates of neuroma formation. CONCLUSIONS: Nerve capping has undergone major advancements since its beginnings and is now a useful option for the treatment or prevention of neuromas. As knowledge of peripheral nerve injuries and neuroma prevention grows, the criterion standard neuroprotective material for enhancement of nerve regeneration can be identified and applied to produce reliable surgical outcomes.

A Historical Perspective on Brachial Plexus Palsy Management: From Ancient Civilizations to the Modern Era.

Evidence of brachial plexus palsies and potential therapies have been identified by investigators across cultures and civilizations. It could be argued that there are early records of brachial plexus injuries in not only literary work but also paintings, sculptures, and ancient medical texts. The compiled ancient evidence in this review provides a historical framework of brachial plexus palsies and potential management techniques that have been utilized from ancient to modern time.

Sagittal Craniosynostosis: Treatment and Outcomes According to Age at Intervention.

The purpose of this study is to describe the treatment strategies and outcomes of nonsyndromic single-suture sagittal craniosynostosis based on the patient's age at intervention. Studies from MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched for patients with nonsyndromic single-suture sagittal craniosynostosis. Inclusion criteria encompassed studies with follow-up of at least 12 months, minimum of 25 patients per cohort, and first-time surgical intervention. The risk of bias in nonrandomized studies of intervention tool [Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I)] was applied. A total of 49 manuscripts with 3316 patients met criteria. Articles were categorized based on age at intervention; 0 to 6, older than 6 to 12, and older than 12 months. Fifteen of the manuscripts described interventions in more than 1 age group. From the 49 articles, 39 (n=2141) included patients 0 to 6 months old, 15 (n=669) discussed patients older than 6 to 12 months old, and 9 (n=506) evaluated patients older than 12 months old. Follow-up ranged from 12 to 144 months. Over 8 types of open surgical techniques were identified and 5 different minimally invasive procedures were described. Minimally invasive procedures were exclusively seen in the youngest patient cohort, while open cranial vault reconstructions were often seen in the 2 older cohorts. Endoscopic surgery and open conservative procedures are indicated for younger patients, while complex open cranial vault reconstructions are common in older patients. However, there is no consensus on one approach over the other. Even with the analysis of this review, we cannot factor a strong conclusion on a specific technique.

The Use of Botulinum Toxin in Raynaud Phenomenon: A Comprehensive Literature Review.

BACKGROUND: Raynaud phenomenon (RP) is a vasospastic condition of the digits that can be primary or secondary to systemic disease. Symptoms are triggered by cold or stress and can cause pain and skin color changes. The chronic ischemia may lead to necrosis, ulceration, and amputation. There are no Food and Drug Administration-approved treatments and cases refractory to pharmacologic and surgical treatments are difficult to control. Local botulinum toxin injections have been increasingly used in the treatment of Raynaud disease and have shown promising results. AIM OF THE STUDY: To examine the outcomes, techniques, and complications of botulinum toxin use for the treatment of Raynaud disease. METHODS: The PubMed database was queried using "botulinum toxin" AND "Raynaud phenomenon" as title key words. Preferred reporting items for systematic reviews and meta-analysis criteria were used. Additional articles were selected while reviewing the references of the articles from PubMed. No time restrictions were followed. Articles of all languages were included. Articles were analyzed for study type, demographics, diagnosis/inclusion criteria, treatment methods, outcome measures, length of follow-up, results, and complications. A positive outcome was defined as subjective improvement in symptoms and/or improvement in the outcome measures. A poor outcome was defined as harm done to the patient by the injection that would not have occurred otherwise. RESULTS: Forty-two clinical studies describing the use of botulinum toxin for Raynaud's phenomenon were found. A total of 425 patients with primary or secondary Raynaud's were treated, with ages ranging from 14 to 91 years. There were 342 women and 81 men, with a female-to-male ratio of 38:9. Outcomes were positive in 96.2% of patients. There were 14.2% of the studies that reported 3.5% of all patients showing no subjective improvement. A single study reported a poor outcome for 1 patient. There were 40.5% of the studies that reported complications, affecting 20.2% of all patients. The most frequently reported complication was transient hand weakness, affecting 44.2% of patients with complications and 8.9% of total patients. Weakness resolved in hours to months after injection. Pain at the injection site lasting minutes to days was reported in 40.7% of patients with complications, and 8.2% of total patients. CONCLUSIONS: Botulinum toxin treatment for RP is effective. Complications are minor and self-limiting.

Repair of Congenital Enlarged Parietal Foramina With Porous Polyethylene Implants.

Enlarged biparietal foramina is an autosomal dominant disorder that is caused by a failure of completion of ossification within the parietal bones. Enlarged parietal foramina measuring more than a few millimeters are uncommon. Even though spontaneous regression has been described, closure is rarely complete, and depending on the size of the resulting defect, an unprotected brain is a concern. There are few reports on the surgical management of persistent enlarged biparietal foramina. This is the first report describing our experience with a custom porous polyethylene implant.

Direct Neurotization: Past, Present, and Future Considerations.

ABSTRACT: Direct neurotization is a method that involves direct implantation of nerve fascicles into a target tissue, that is, muscle fibers, skin, cornea, and so on, with the goal of restoring aesthetic, sensation and or functional capacity. This technique has been implemented since the early 1900s, with numerous experimental and clinical reports of success. Applications have included both sensory and motor neurotization of muscle, as well as protective sensory provision for other organs. These techniques have been used to restore corneal sensation, repair brachial plexus injuries, reestablish tongue movement and function through direct tongue neurotization, and reinnervate multiple facial muscles in patients with facial paralysis. Most recently, these methods have even been used in conjunction with acellular cadaveric nerve grafts to directly neurotize skin. Indications for direct neurotization remain limited, including those in which neural coaptation is not feasible (ie, surgical or traumatic damage to neuromuscular junction, severe avulsion injuries of the distal nerve); however, the success and wide-range application of direct neurotization shows its potential to be implemented as an adjunct treatment in contrast to views that it should solely be used as a salvage therapy. The purpose of the following review is to detail the historic and current applications of direct neurotization and describe the future areas of investigation and development of this technique.

Long-term Effects of Repeated Botulinum Toxin Injection in Cosmetic Therapeutics.

BACKGROUND: Botulinum toxin (BT), a potent neurotoxin, has been used in clinical medicine since the 1970s for cosmetic and therapeutic purposes. Studies have consistently shown positive outcomes with a very limited adverse effect profile and a conventional understanding that results dissipate after 3 to 5 months. However, more recent evidence suggests that changes in muscle composition, function, and appearance persist for much longer, even years. To examine the potential implications of these findings on cosmetic use of BT injections in reduction of skin lines and wrinkles, we first needed to further our understanding of the current literature on long-term outcomes after repeated BT injections. METHODS: A comprehensive review of the literature on long-term outcomes after repeated BT injections for cosmetic indications was performed. We evaluated the study designs, and results were compared. RESULTS: A total of 22 publications met our inclusion criteria, of which 14 were clinical trials. Few studies extended outcome measurement past 6 months postinjection, and many were funded or supported by industry. However, the studies that extended follow-up saw persistent changes after BT injection, in some cases as far as 4 years postinjection. CONCLUSION: The current body of knowledge on the long-term results after repeated cosmetic BT injections is very limited, and the available literature provides insufficient evidence on how prolonged effects could alter clinical use of BT. Further clinical studies with extended follow-up periods with inclusion of both subjective and objective measured outcomes of appearance and muscle function are required to better understand the long-term impacts of repeated BT injections.

A Historical Perspective on the Management of Facial Paralysis: From Ancient Civilizations to the Modern Era.

ABSTRACT: Documented evidence of facial nerve paralysis (FNP) and its treatment have been discovered in many early civilizations dating back centuries. Early records are present in art and scripts across ancient civilizations and have laid the groundwork for the implementation of many managements used in modern practice. Although the current management of FNP is still evolving, it includes a complex and multimodal spectrum of options ranging from pharmacologic therapy to facial physical therapy and neuromuscular training, and surgical facial reanimation interventions via static and dynamic procedures. The aim of this review is not to provide an up-to-date glossary of modern management options but rather to discuss the historical evidence of FNP and treatments leading up to current techniques and practices.

Eye Sphincter Reanimation in Facial Paralysis: Evaluation, Indications, Techniques, and Outcomes.

ABSTRACT: Facial nerve paralysis (FNP) sequela includes dysregulation of the ocular surface protective mechanism, nasolacrimal system pump failure and punctal eversion causing chronic epiphora, foreign body sensation, corneal injury, and, in the most severe cases, visual loss, particularly in the presence of comorbid corneal hypesthesia. Concerns over the ocular surface protection in FNP patients have led to the development of numerous static and dynamic procedures. While initial assessment of the FNP patients is complex and requires a comprehensive understanding of the blink reflex physiology, clinical evaluation and the use of additional work should be directed toward potential eye sphincter reanimation using a multidisciplinary approach. As with any treatment algorithm, numerous factors must be considered to provide an individualized treatment plan. In the case of FNP, it is important to consider denervation time, patient age, cause of paralysis, and neurologic severity of the paralysis. The aim of this article is to provide a thorough review of the physiology of the blink reflex, evaluation of the eye sphincter mechanism in FNP, and a comprehensive treatment algorithm incorporating static and dynamic procedures, along with a historical perspective.

A Comprehensive Review on the Supraclavicular Flap for Head and Neck Reconstruction.

ABSTRACT: The supraclavicular artery flap (SCF) is a highly vascularized fasciocutaneous flap overlying the shoulder. The flap was first described in 1979 by Lamberty but did not gain popularity until much later due to lack of a reliable technique. The main advantages of using the SCF include avoiding microsurgical techniques, requiring only a single-stage operation, shorter operative time compared with alternative options, and a wider patient population including those with comorbidities who may be excluded from more extensive operations including free flaps surgeries. The SCF has been successfully performed on individuals with advanced age, poor nutrition, cachexia, obesity, diabetes, tobacco use, severe chronic obstructive pulmonary disease, hypertension, coronary artery disease, peripheral vascular disease, supraventricular tachycardia, atrial fibrillation, heart failure, asthma, and steroid use. The largest disadvantages of the SCF include the possibility of distal tip necrosis, size limitation without pre-expansion, and a moderately visible donor site scar. The following review and meta-analysis of the SCF details its use historically as both an island and a pedicle flap, and its application in head and neck reconstruction.

The Bridged Digital Artery Perforator Flap as an Alternative Reconstructive Option for Dorsal Digital or Toe Soft Tissue Defects.

BACKGROUND: Dorsal digital soft tissue defects are considered among the most challenging to reconstruct. Numerous treatment options are proposed, including advancement flaps, antegrade, retrograde flow flaps, adipofascial flaps, and digital artery perforator flaps. However, the optimal treatment remains controversial. The concept of the "bridge principle," consisting of the indirect transfer of the flap to the defect area through a muscular bridge, has recently introduced by authors for medial canthal reconstruction. The aim of the study was to examine the feasibility of its application in digital reconstruction for dorsal defects and the development of a new flap. The utilization of the dorsal subcutaneous adipofascial digital or toe tissue as a "bridge" led to description and development of bridged digital artery perforator flaps as an alternative treatment of such defects. METHODS: From November 2017 to September 2019, a series of 14 patients (mean age of 57.1 years) suffered from dorsal digital or toe soft tissue defects of different dimensions and sustained reconstruction with this new technique. RESULTS: Twelve digits and 2 toes have been concerned. The mean size of the defects was 1.3 × 1.1 cm. All flaps survived without a sign of venous congestion. No functional digital or toe problems were observed during the follow-up period (mean of 11.6 months). Minor wound dehiscence presented in 2 cases (2 of 14 [14.3%]) and a transient skin swelling around the flap in 1. CONCLUSIONS: A new concept was introduced to resolve a challenging problem. Initial outcomes are very encouraging. These flaps could be a valuable and reliable reconstructive option.

Eyelid Reconstruction: An Algorithm Based on Defect Location.

ABSTRACT: Eyelid reconstruction is a complex topic. This review looks at articles from 1990 to 2018 on eyelid reconstruction that had at least 10 patients and a mean 6 month follow-up. The authors present the results of our findings and propose an algorithm to guide the surgeon in choosing the best technique based on location, size, and lamella. Defects less than 1/3rd of the upper or lower eyelid may be closed primarily. Anterior and posterior lamella defects of the lower eyelid greater than 1/3rd in size should be reconstructed with a double mucosal and myocutaneous island flap. Those greater than 50% in size should be recreated with a Tripier flap for the anterior lamella and conchal chondroperichondral graft for the posterior lamella. For total lid reconstruction, a Fricke flap is best for the anterior lamella and the tarsoconjunctival free graft/lateral orbital rim periosteal flap is best for the posterior lamella. Fullthickness defects between 1/3rd and 2/3rd in size of the upper eyelid should be reconstructed with a myotarsocutaneous flap and those greater than 2/3rd should be reconstructed with a Cutler-Beard flap for the anterior lamella and auricular cartilage for the posterior lamella. For the medial canthal region, the island pedicle and horizontal cheek advancement flap is recommended for the anterior lamella and a composite upper lid graft for the posterior lamella. For the lateral canthal region, a bilobed flap is recommended for the anterior lamella and a periosteal flap for the posterior lamella.

Pediatric Dog Bites: A Review of 1422 Cases Treated at a Level One Regional Pediatric Trauma Center.

BACKGROUND: Children under the age of 14 account for over 40% of the almost 900,000 annual hospital visits associated with dog bites. Care for dog bites ranges from simple wound irrigation to complex surgical reconstruction. Due to a number of factors, children frequently sustain dog bites to highly vulnerable regions, often necessitating intervention by plastic surgeons. METHODS: This retrospective study analyzed data from the 1422 pediatric patients who sustained dog bites and presented to the Le Bonheur Children's Hospital Emergency Room from January 2011 to May 2017. RESULTS: The typical pediatric dog bite case was male (63.5%), African-American (57.4%), and less than 10 years old (69.4%). The head and neck were the most commonly affected areas (64.7%). Of the head and neck regions, the cheeks and lips were the most frequently injured structures (34.5%). Hospital admission was required for 188 patients (13.2%) and operative repair was deemed necessary in 16.9% of all cases. Of the patients requiring inpatient operative repair, most (78.3%) were discharged in less than 24 hours. Operative complications occurred in 5.8% of all cases, with infections accounting for the majority (92.9%). No fatal dog bites occurred in this study. CONCLUSIONS: Age, bite location, and number of bites sustained are several factors of significance, which may aid the novice plastic surgeon in identifying, which pediatric dog bite cases will require surgical intervention.

Temporoparietal Fascial Free Flap: A Systematic Review.

ABSTRACT: The temporoparietal fascial flap (TPFF) is a versatile tool used in head and neck reconstructive surgeries as well as distal upper and lower extremity reconstructions. Depending on the anatomical location and characteristics of the recipient site soft tissue defects, harvesting techniques for TPFF retrieval may include elevation as a pedicle or a free flap, inclusion of the temporalis muscle and/or adjacent calvarial bone as a composite flap. The TPFF as a free flap is not only used for soft tissue coverage of various defects, and it can be used as a joint gliding surface with coverage of nerve and tendons after repair or trauma. This article includes a systematic search of the medical literature for indications, historical background, techniques, current perspective, and complications along with the pros and cons of the free TPFF compared with other potential reconstructive options.

Distraction Osteogenesis in Craniofacial Surgery: Past, Present, and Future.

ABSTRACT: Distraction osteogenesis (DO) is considered one of the treatments of choice for the surgical correction of malformations of the craniofacial skeleton. This is due to its ability to generate bone at the distraction site along with the accompanying soft tissue changes, the possibility to combine DO with traditional orthognathic procedures and the successful reported long-term outcomes following its application to various craniofacial deformities. The aim of this review is to present an overview of the literature on the evolution of DO applications in craniofacial surgery through the last 35 years.

Implications of Free Temporoparietal Fascial Flap Reconstruction in the Pediatric Population.

ABSTRACT: The temporoparietal fascial flap (TPFF) is a versatile tool that can be used in the reconstruction of head and neck and distal upper and lower extremity defects. The TPFF may be harvested as a pedicle or free flap as well as with the temporalis muscle and/or adjacent calvarial bone as a composite flap. As a free flap, the TPFF has been used as a joint gliding surface with coverage of nerves and tendons, for extremity soft tissue repair, for tracheal and pharyngeal coverage and for defects of the nose, scalp, and auricle. This article focuses on the use of the free TPFF in the pediatric population through systemic review of the medical literature. Current perspectives on the use of this flap and microsurgery in general in pediatric patients are addressed.

Comprehensive Review of the Submental Flap in Head and Neck and Facial Reconstruction: What Plastic Surgeons Need to Know.

ABSTRACT: Since its first introduction by Martin and colleagues (1993) and with further revisions by Sterne et al (1996), the submental artery flap (SMAF) has proven to be an effective, reliable, safe, and valuable option in head, neck, and facial reconstructive surgeries. The SMAF utilizes a long pedicle based on the submental artery, a branch of the facial artery, which provides good reach to the lower two-thirds of the face with excellent cosmetic outcomes. It also maintains a good skin color match for facial and cervical defects with a mostly hidden donor site scar (in the majority of cases the donor site can be primarily closed after raising the flap). Although the use of the SMAF is associated with high patient and surgeon satisfaction along with low rates of complications, disadvantages including flap thickness and the hair-bearing nature of the submental skin, which may be problematic for coverage of orofacial defects, especially in male patients. Although it has been almost 30 years since its introduction, and the SMAF has been successfully used in over 500 reported cases of pediatric and adult patients, a comprehensive review of the different aspects of the SMAF is lacking in the medical literature.

The History of Alloplastic Ear Reconstruction for Microtia.

Microtia reconstruction is a unique and challenging field in reconstructive surgery. In the early 20th century, many different alloplastic materials have been used in an attempt to recreate the fibrocartilaginous framework of the native ear. These materials include celluloid, tantalum wire cage, nylon mesh, polyethylene, and acrylic. The first standard for alloplastic microtia reconstruction, silicone, is one fraught with complications and failures. This alloplastic material is walled off by the host and prone to scar tissue formation and extrusion. Alloplastic microtia reconstruction largely shifts to porous polyethylene, where the results are markedly superior. This is attributed to the porous structure of porous polyethylene, which allows tissue ingrowth. Moreover, the use of the temporoparietal fascia flap for total coverage of the implant has impressively lowered the risk of implant extrusion. However, there is paucity in the literature regarding the evolution of alloplastic microtia reconstruction, especially characterizing historical mistakes, significant technique evolutions, and drawbacks/advantages of materials. This review serves as a guide both to avoid repeating mistakes and to improve outcomes.

The Current Status of the Autologous Fat Grafting for Pediatric Craniofacial Patients.

Since its first introduction, autologous fat grafting (AFG) has undergone multiple refinements and has become a common treatment option within plastic surgery. It is a safe, quick, economical, and minimally invasive method for volume augmentation and is finding its own indications in the pediatric craniofacial surgery patients. Because there is currently a paucity of literature regarding the use of AFG in the pediatric population compared with the adults, the authors performed a systematic review of the literature using PubMed, Cochrane Library databases, and the Journal of Plastic and Reconstructive Surgery using the terms of fat grafting/lipofilling, fat grafting, and craniofacial surgery to include articles that contained pediatric patients. While reviewing AFG in the pediatric craniofacial patients, indications, technique, and challenges were specifically evaluated and an algorithm of approach was proposed. In current practice, the choice of microvascular free flap versus AFG is one of the surgeon preferences on a case-by-case basis. With the low complication rate and ease of use, selection of AFG for the repair of soft tissue defects in pediatric craniofacial patients is increasing and may come to surpass use of traditional invasive methods such as free flaps. It should also be considered as a useful adjunct to other concurrent invasive procedures, that is, bony adjustments.

Cadaver Nerve Grafts: Past, Present and Future.

Nerve grafts represent an invaluable tool, when reconstructing nerve defects of more than 1 cm. Historically, the criterion standard use of autografts has relied on the premise of using nonessential sensory nerves to fulfill the principle of replacing "like with like," while simultaneously minimizing the infliction of undue morbidity on the patient. The reconstructive surgeon thus faces a dilemma when extensive nerve damage requires reconstruction, or when donor nerves are not available or limited such as in the pediatric population. Cadaver nerve grafts (CNG) uniquely allow for reconstruction of large nerve lesions without the presence of host morbidity. The following article reviews the use of CNG, its indications, advantages, and disadvantages, as well as provides some case studies of real-world application. In addition, an insight into the future perspectives of CNG is provided.